Review of “Pathologies of Power” by Paul Farmer

In Pathologies of Power: Health, Human Rights, and the New War on the Poor, Paul Farmer combines his experiences as a physician and anthropologist in the Third World to bring forth evidence and analysis of poverty.  While primarily focused on health, and profiling the effects of Tuberculosis, AIDS and other diseases on particular locales, his experience in treating patients beaten by members of military dictatorships and those who experience malnourishment point to deeply social health problems.  As he quickly demonstrates, military attacks on civilians and AIDS are equally socially determined problems.

In Haiti and Chiapas, Farmer explains, the breakdown of subsistence living and the problems of landlessness are connected to relocation and infrastructure-building projects of governments and corporations.  The displaced peasants have their cultural and material production disrupted, are moved to infertile land, and thus starvation, malnutrition and social problems create multiple crises of poverty.  Because poor health and death are inextricably linked to political and economic structures far outside the control of those affected by it, Farmer considers this a case of structural violence.  This structural violence is rooted both in local and global political and economic phenomena, and Farmer provides a successful demonstration of how each create circumstances which cause health problems to flourish, and exacerbate the suffering of the poorest of people.  In the case of Haiti, the military junta and US foreign policy aid one another for their own purposes, and collaborate to contribute to the exacerbation of disease and starvation among the poor.

Farmer makes the moral argument, throughout the text, but particularly at the beginning of Part II of Pathologies of Power, that health care is a universal human right.  This argument is not without a distinct history in international politics and liberation theology.  The author frequently calls upon the Universal Declaration of Human Rights to argue that this point is as often a discursive element of rights speech as it is absent from foreign policy.

Farmer is sharply critical of the purposes of the market approach to medical care, and the net effect this has had on the health of the world’s poor.  Calling upon the ethical arguments of economist, Amartya Sen, and of liberation theologists, the author positions the overall health and the lack of suffering as a moral priority above any concerns for market economics.  Further, he is critical of  cultural relativism, which he considers dominant within medical ethics discussions and anthropological literature.  He argues that this relativism effectively leads to a lack of advocacy on the part of the poor and sick from doctors and anthropologists, who he says maintain a general ambivalence toward the suffering of the impoverished in the Third World.

From a perspective critical to globalism, this text provides both insights and problems.  Farmer clearly demonstrates that the degree of poverty in the Third World is deeply dependent upon the exploitation of global capitalism, and the collaboration of local despots with the interests of capital accumulation over the people.  Further, despotic regimes, such as the military junta in Haiti, were largely the creation of both US foreign policy and a long colonial history tied to the expansion of the global capitalist system.

Three aspects of globalism Farmer fails to address are: 1) the roots of many health problems in industrial production and industrialized modern medicine; 2) the destruction of chthonic cultures by industrialization and colonialism; and 3) the breakdown of traditional medicine and healing arts.  These three issues are all closely interrelated.   In criticizing the role of globalism in exacerbating the sickness and suffering of the poor, we might consider that the technological domination of nature and the quest for unlimited economic growth, both an intrinsic component of the global capitalist system, have had devastating effects upon the health of all people (see Ashton & Laura, 1999; Khor, 1992).

These issues, however, conflict with a seeming unflinching faith in the benefits of modern medicine, and in the extension of Western models for health care into all communities.  In fact, we might see that Farmer’s fix to problems of suffering in the Third World might aid in these impacts of globalism on traditional societies.  However, we must remember that often modern diseases require modern cures.  The question then might be how can we conceive of disease prevention in political terms, in addition to medical care.  Farmer acknowledges the structural and political causes.  For this, he provides valuable ethical arguments and medical solutions.  But these lack the ability to challenge the wave of modernization that is causing many of these problems and the ability for local communities to develop sustainable local solutions.

Although Farmer challenges the chauvinism of Western cultures that blame that sick for their plight, he does not challenge the Western view of suffering, its faith in the mythology of technological progress, or the belief in the superiority of modern Western healing that relies heavily upon complex technologies.  With regard to Western conceptions of suffering, Serge Latouche reminds us that

“[Third World societies] conserve different attitudes toward the old and the sick.  Illness and ageing are not considered as natural curses that separate the individual from the world of the living and that must be treated in isolation, shame and guilt …  Suffering has only become unbearable in the West because it no longer has meaning.  The fact that pain is inherent to the human condition, and perhaps necessary, highlights to what extent its refusal and trivialization contribute to our impoverishment” (2010, 291).

The setting of universal health standards, universal means of attaining them, and universal rights to access to these means effectively creates a globalized model for health care.  The International Forum on Globalization has addressed the problems of universal standards, writing that they

“not only violate the democratic right to self-determination but also fail to take into account differing local conditions and preferences.  Those on this side of the argument call for measures to secure the right of nations and even localities to adopt standards of their choosing appropriate to their circumstances …  The less the self-reliance of a community or nation, the greater its external dependence and the greater the need for global uniform rules to avoid a downward pressure on standards everywhere.  By the same token, the greater the self-reliance of a community or nation, the greater the scope for local flexibility and adaptation to local circumstances” (2002, 9-10).

Thus it could be argued that universal standards undermine the potential for self-reliance within and the sustainability of a given community.  Farmer’s approach could be positioned as medical dependency, fostering the same medical relationship between the core and periphery that economic globalization creates.

Farmer is quite aware of this critique, which he dismisses, off-the-cuff, with an ad hominem attack, labeling it a “Luddite trap” (2005, 146).  I call this reductio ad Luddite.  Webster & Robins characterize this fallacious rhetorical devise thusly:

“[T]he very word ‘Luddite’ so successfully abuses any opposition …  Luddism is portrayed as all that is negative, hopeless, and deluded … The accusation of ‘Luddism’ has become a ritual incantation that forecloses debate on the social and political meanings, the causes and effects, of technological change.  For all concerned, it is a charged and opprobrious label: if you do not favor ‘progress,’ ‘improvement,’ the ‘new,’ the ‘future’ itself, then you risk the dread charge being laid at your door” (1986, 1-2).

Farmer “believe[s] the Luddites are dead wrong.  We all should have access to the fruits of modern technology, especially those who most need it” (2005, 175).

Rather than resort to a similar rhetorical trick, and label Farmer a “cultural imperialist,” I will instead rely on a brief encapsulation of the position of the original Luddites.  The Luddites recognized that 1) technological change necessitates social change, often irreversibly; 2) that advanced, complex technologies generally impose social hierarchies; and 3) that complex technologies are necessarily alienating (see Binfield, 2004; Sale, 1995).  We can extrapolate these positions and apply them to medical technologies.  Jerry Mander reminds us that “Western medicine cannot be separated from the whole web of technologies that are its parents and children: computers, certain reproductive interventions, biotechnology, and genetics, all of which are problematic in some way” (1991, 27).

Westernized, technologized health care is inherently hierarchical.  Farmer poses a moral system to manage this hierarchy, critiquing structural violence and positioning (Westernized) health care as a universal human right.  What kind of political and social structures would such a system require to maintain these rights?  Who would be accountable, and how?  Farmer acknowledges that the Universal Declaration of Human Rights is a rather hollow proclamation, and that, indeed, the majority of the world’s population does not have a means to exercise these rights. If the UN and its declarations are failing what might Farmer suggest would succeed?

The Luddites might suggest that this has not to do with a lack of moral resolve or structures for administering care and holding impediments (whether structures or people) accountable for standing in the way.  Technologies do not simply fall from the sky.  They also do not fall in such abundance that all can have equal, universal access to them.  Farmer fails to acknowledge that many medicines rely upon unsustainable and destructive practices, which rely upon exploitation of natural resources, animal research, testing on (mostly extremely impoverished) human guinea pigs.  Further, he ascribes to the failures of distribution of medicines (such as in the case of the Russian prisons) to poor management and the prioritization of economics to health care.  Scarcity is viewed in purely economic terms, and medicines are viewed as neutral technologies, that exist outside of the paradigm of structural violence.  The wealth that generates advanced medicine and training of doctors and nurses in large supply was accumulated through exploitation and political domination.  It is no wonder that First World nations must supply its doctors to the Third World, as it is First World privileges of wealth and leisure that create the social conditions to foster an abundance of modern medical caregivers.

Farmer brings to light important evidence of global inequality, and the exploitation of the poor.  Further, he elucidates some important ethical arguments regarding health care in the global capitalist system.  Perhaps a few more ethical questions should be asked:

  • Should we fail to foster traditional, self-reliant systems of care by replacing them with dependence upon the West, helping further institutionalize technology-dependent modern medicine into their social infrastructure?  If we take this route, will we help to institute a wholly totalitarian system of care, thus requiring constant social management to attempt just distribution of the rewards?
  • Where do medical technologies come from?  Could we have these without structural violence?  Without animal testing and exploitation of the poor as human guinea pigs?  Without exploitation of labor and resources to manufacture the technologies and pharmaceuticals?

Farmer enables deeper questions to be asked, and the elevation of the poor to the highest level of priority in considerations of care and medicine.  For this Pathologies of Power can be commended as an important – if problematic – work of medical anthropology.

Works cited:

Ashton, John and Laura, Ron, The Perils of Progress: The Health and Environment Hazards of Modern Technology, and What You Can Do About Them, London: Zed Books, 1999. Print.

Binfield, Ed, edited by, Writings of the Luddites, Baltimore, MA: The John Hopkins University Press, 2004. Print.

Farmer, Paul, Pathologies of Power: Health, Human Rights, and the New War on the Poor, Berkeley, CA: University of California Press, 2005. Print.

International Forum on Globalization, the, Alternatives to Economic Globalization, San Francisco, CA: Barrett-Koehler Publishers, 2002. Print.

Khor, Martin, “Development, Trade and the Environment: A Third World Perspective,” in The Future of Progress: Reflections on Environment and Development, (revised edition) edited by Edward Goldsmith, et al., Devon: Green Books, Ltd. Print.

Latouche, Serge, “Standard of Living,” in The Development Dictionary, edited by Wolfgang Sachs, London: Zed Books, 2010. Print.

Mander, Jerry, In the Absence of the Sacred: The Failure of Technology & the Survival of the Indian Nations, San Francisco, CA: Sierra Club Books, 1991. Print.

Sale, Kirkpatrick, Rebels Against the Future: The Luddites and Their War on the Industrial Revolution, Lessons for the Computer Age, Reading, MA: Addison-Wesley Publishing Company, 1995. Print.

Webster, Frank, and Robins, Kevin, Information Technology: A Luddite Analysis, Norwood, NJ: Ablex Publishing Company. Print.

3 thoughts on “Review of “Pathologies of Power” by Paul Farmer

  1. Hi Ben,

    Please shoot me an email when you get a chance. I’m an editor for Catalyst: A Social Justice Forum and I have a short article about Paul Farmer that I’d love to get you to review, if you’re up to it.

    I look forward to hearing from you,


    p.s. I could not find your email address on here!

  2. Perhaps a sticking point, but we who do work in the “Third World” rarely call it that, not only for its condescending implications, but also since the term itself is now irrelevant given the fall of the Soviet Union in late 20th century.

    I agree that developing nations (who do not make up a “world”) need to embrace sustainable solutions to provide health care to their populations. The nature of this sustainability, though, must also include so-called “western” medicine in the form of local factories and development of pharmaceuticals targeted at health challenges specific to their local needs.

    The utility of indigenous medicine of all locales should not be discounted, but its inadequacies also should not be ignored. Where I do work the biggest killers and threats to human health are malnutrition, TB, malaria and HIV. There are no effective indigenous solutions to any of these diseases except the first. While your point of western hegemony through medicine must be taken seriously, the demands of local populations for medicines that work, western or not, must also be taken seriously.

  3. Nonsense, your critique of Farmer is nonsense. As a Marxist myself, of the autonomist variety, and as someone with a background in public and community health, as someone who worked for years at a free clinic, at a community health center, and on the streets with persons with HIV, drug users, homeless, the poor in general, I would call this one of the five best books I have ever read. I am sixty five, have been involved in movement work of all kinds since the 60s, spent time in federal prison for my political activities, and remain active today. Farmer may not speak the language you like, but he lives and works in the real world, he may not tackle every single problem you can come up with in one book, but really, name someone who does. I would also add that many of your criticism are just plain wrong. Your comment, just for example, “Three aspects of globalism Farmer fails to address are: 1) the roots of many health problems in industrial production and industrialized modern medicine; 2) the destruction of chthonic cultures by industrialization and colonialism; and 3) the breakdown of traditional medicine and healing arts,” is just plain wrong. He does address all of these. How you miss this if you know anything about Farmer, or even know him from only this book is beyond me. If you have read other books by Farmer, you would note that he also never opposes traditional medicines he merely doesn’t oppose Western medicine either. He also has opposed the hierarchical nature of healthcare. For example, he specifically states in one part of this book that what he calls medicine or medical care or medical workers includes doctors, nurses, community healthcare workers and all other healthcare workers. He throughout the book mentions all the places doctors get it wrong, how the best thing they can do is listen to the poor not tell them what to do, to learn from the poor not preach to them. Farmer often in all his books lets the poor speak for themselves and then he, in turn, often quotes them. To deny to the world the most advanced medical care possible, to the poor of the world, due to some ideological, theoretical purity is to participate in the very inequality which Farmer addresses. Farmer makes clear a central point. That point is that we have the means, the knowledge, the ability, and the resources right now to prevent not only unnecessary deaths from infectious diseases and other illnesses, to provide quality health care to everyone, he tells us that we can do the same for other problems like hunger, poverty, etc. You may long for a past where millions died from diseases modern medicine can now cure and prevent, but I don’t. I long for a future where every single person is just as important as the next. Farmer, actually goes beyond this (and I happen to agree), he believes in preferential treatment for the poor and oppressed. It is true that Farmer does not offer a perfect outline on how to get from here to there, but no one else has accomplished that either. We are still here, after all, and we are not there. Finally, I must add that unlike most people who sit around talking about this stuff, Paul Farmer actually acts right now in the real world, with real people, right now. He does not merely pontificate. He does not merely posture. He does not merely protest. He isn’t merely waiting for the revolution.

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